6265 Crain Highway 5722 Livingston Road

Dr. Patrick S. Cieplak, D.D.S.

6265 Crain Highway 5722 Livingston Road

LaPlata, Md. 20646 Oxon Hill, Md. 20745

(301) 609-9999 (301) 839-1917

Today’s Date:______

Who Referred you to our office? ______

Patient Name:______Date of Birth:______

Last First Middle Initial

Home Address: ______Home Phone:______

If minor, responsible party:______

Last First Middle Initial

Date of Birth: ______Relationship:______Sex: Male Female

Home Phone: ______Work Phone: ______Ext:_____

Home Address: ______

Date of Birth: ______Social Security Number:______

Employer’s Name: ______

Dental History

Reason for today’s visit:______

Previous dentist:______Address:______

Date of last dental exam:______Last cleaning:______X-rays:______

Please mark if you have had problems with any of the following:

Bad Breath Periodontal treatment

Bleeding gums Sensitivity to cold

Clicking or popping jaw Sensitivity to hot

Food collection between teeth Sensitivity to sweets

Grinding teeth Sensitivity when biting

Loose teeth or broken fillings Sores or growths in your mouth

How often do you floss?______How often do you brush?______

Medical History

Physician’s name:______Phone number:______

Date of last visit:______Have you had any serious illness or operations? Yes No

If yes, please describe: ______

Have you ever had any blood transfusions? Yes No If yes, give dates: ______

(Women) Are you pregnant? Yes No Nursing? Yes No

Taking birth control? Yes No

Please mark if you have had any of the following:

AIDS Epilepsy Pacemaker

Anemia Fainting Psychiatric Care

Arthritis, Rheumatism Glaucoma Radiation Treatment

Artificial Heart Valve Headaches Respiratory Disease

Artificial Joints Heart Murmur Rheumatic Fever

Asthma Heart Problems Scarlet Fever

Back Problems Describe:______ Shortness of Breath

Blood Disease Hemophilia Skin Rash

Cancer Hepatitis Stroke

Chemical Dependency High Blood Pressure Swelling in Feet/Ankles

Chemotherapy HIV Positive Thyroid Problems

Circulatory Problems Jaw Pain Tobacco Habit

Cortisone Treatments Kidney Disease Tonsillitis

Cough, Persistent Liver Disease Tuberculosis

Coughing up of Blood Mitral Valve Prolapse Ulcer

Diabetes Nervous Problems Venereal Disease

Medications: ______

______

Allergies:

In case of emergency, who should be notified?:______

Last First Middle Initial

Relationship:______Home Phone:______Work Phone:______

Please Read and Sign:

The information that I have given is correct to the best of my knowledge. I understand that this information will be held in the strictest of confidence. I also understand that I am responsible for notifying Dr. Cieplak’s Office if there are any changes in this patient’s medical status.

Responsible Party’s Signature Date

I understand that Dr. Cieplak does not participate with any insurance companies nor does he accept assignment of benefits. I am aware that I am financially responsible for all charges at the time services are rendered. If I wish Dr. Cieplak’s office to submit a claim to my insurance company on my behalf so that I may be reimbursed directly, I understand that I am responsible for supplying Dr. Cieplak’s office with my complete insurance information. I also understand that Dr. Cieplak is in no way affiliated with any insurance companies, and, therefore, cannot be held accountable for any payment or denial of payment that I may receive from my insurance.

Responsible Party’s Signature Date

DO NOT WRITE BELOW THIS LINE

Updates

Have there been any changes in your health since last appointment? Yes No

If yes, explain:______